Anatomy and diagnosis

ANATOMY OF THE FEMALE

REPRODUCTIVE SYSTEM

Anatomy and diagnosis

POSITION OF THE
UTERUS



Suspension- support for the uterus by
ligaments



Supposition- support for the uterus by
fasciae



Ante(retro-)flexion- the angle between the
long axis of the corpus and the cervix



Ante(retro-)version- the angle between the
long axis of the cervix and the vagina

Anatomy and diagnosis

Anatomy and diagnosis

The muscles supported the
uterus



Urogenital diaphragm:

•

Deep transverse muscle of perineum

•

Sphincter muscle of urethra



Pelvic diaphragm:



Levator ani muscle



Coccygeal muscle



Superficial layer of muscles:

•

Bulbocavernous muscle

•

Ischiocavernous muscle

•

Superficial transverse muscle of perineum

•

Anal sphincter muscle

Anatomy and diagnosis

Anatomy and diagnosis

Anatomy and diagnosis

Anatomy and diagnosis

Anatomy and diagnosis

Anatomy and diagnosis

Gynecological examinations

Screening examinations

Basic examinations

Additional

examinations

Anatomy and diagnosis

Basic examination



History

complaints, age, menstrual history (first menstrual

period, last menstrual period), obstetric history

(gravidity and parity, abortions), past surgery, cervical

procedures, diseases, applied hormonal therapy etc.



Physical examination



Gynecological examination



Breast examination

Anatomy and diagnosis

Additional examinations



Colposcopy→ biopsies of suspicious areas
of cervical disc; cervical conisation



Transabdominal and transvaginal
ultrasonography,



Labolatory studies,



HSG,



diagnostic laparoscopy and hysteroscopy

Anatomy and diagnosis

Screening examinations



Pap smear: annually from onset of
sexual

activity or age

18

when suspicious results repeat after 3 months



Mammography: at the age of 40, next
after 5

years

at the age of >45 every

year

Anatomy and diagnosis

Pelvic examination

•

Inspection and examination of the
external genitalia

•

Speculum examination

•

Pap smear

•

Cultures

•

Bimanual examination of the uterus and
adnexa

•

Per rectum examination

•

Rectovaginal examination

Anatomy and diagnosis

Anatomy and diagnosis

ULTRASONOGRAPHY

Anatomy and diagnosis

Ultrasonography, pelvic. Transabdominal
longitudinal view of the female pelvis.

bladder

Anatomy and diagnosis

Ultrasonography, pelvic. Transabdominal
transverse view of the female pelvis: The
bladder is rectangular.

Anatomy and diagnosis

Ultrasonography, pelvic. Endovaginal

longitudinal view of the uterus: The
endometrial stripe (st) is thickened.

Anatomy and diagnosis

Ultrasonography, pelvic. Endovaginal

view of the ovary: Note its location
adjacent to an iliac vessel.

Anatomy and diagnosis

Pap Smear



Papanicolau



Bethesda

Anatomy and diagnosis

Pap smear classification

Pap smear classification

Papanicolaou (1943)- normal

Papanicolaou (1943)- normal

images

images



Class I. Normal cells of squamous

Class I. Normal cells of squamous

epithelium. Clean background of

epithelium. Clean background of

specimen. Leukocytes can occur.

specimen. Leukocytes can occur.



Class II. Normal cells from each line of

Class II. Normal cells from each line of

squamous epithelium. Inflammatory and

squamous epithelium. Inflammatory and

metaplastic cells, cervical cells of

metaplastic cells, cervical cells of

columnar epithelium, endometrial cells,

columnar epithelium, endometrial cells,

leukocytes, bacteria, Trichomonas

leukocytes, bacteria, Trichomonas

vaginalis, mucous.

vaginalis, mucous.

Anatomy and diagnosis

Pap smear classification

Pap smear classification

Papanicolaou (1943)- abnormal

Papanicolaou (1943)- abnormal

images

images



Class III. Normal and inflammatory cells

Class III. Normal and inflammatory cells

from each line of squamous and glandular

from each line of squamous and glandular

epithelium and dysplastic cells.

epithelium and dysplastic cells.



Class

Class

IV.

IV.

Like

Like

III

III

class and sparse

class and sparse

neoplastic cells

neoplastic cells

.

.

Erythrocytes can occur.

Erythrocytes can occur.



Grupa V.

Grupa V.

Large number of neoplastic cells

Large number of neoplastic cells

.

.

Large number of erythrocytes in

Large number of erythrocytes in

background of specimen.

background of specimen.

Anatomy and diagnosis

THE BETHESDA SYSTEM



1988



1991



2001

Anatomy and diagnosis

BETHESDA SYSTEM 2001

SPECIMEN TYPE: Indicate conventional smear (Pap smear) vs. liquid-based vs. other
SPECIMEN ADEQUACY
- Satisfactory for evaluation (describe presence or absence of endocervical/transformation

zone

component and any other quality indicators, e.g., partially obscuring blood,

inflammation, etc)

- Unsatisfactory for evaluation ... (specify reason)
- Specimen rejected/not processed (specify reason)
- Specimen processed and examined, but unsatisfactory for evaluation of epithelial

abnormality

because of (specify reason)
GENERAL CATEGORIZATION (optional)
- Negative for Intraepithelial Lesion or Malignancy
- Epithelial Cell Abnormality: See Interpretation/Result (specify ‘squamous’ or ‘glandular’

as

appropriate)
- Other: See Interpretation/Result (e.g. endometrial cells in a woman > 40 years of age)
AUTOMATED REVIEW
If case examined by automated device, specify device and result.
ANCILLARY TESTING
Provide a brief description of the test methods and report the result so that it is easily

understood by the

clinician.

Anatomy and diagnosis

BETHESDA SYSTEM 2001

INTERPRETATION/RESULT
NEGATIVE FOR INTRAEPITHELIAL LESION OR MALIGNANCY (state

whether or not there are organisms or other non-neoplastic findings)

ORGANISMS:
- Trichomonas vaginalis
- Fungal organisms morphologically consistent with Candida spp
- Shift in flora suggestive of bacterial vaginosis
- Bacteria morphologically consistent with Actinomyces spp.
- Cellular changes consistent with Herpes simplex virus
OTHER NON-NEOPLASTIC FINDINGS (Optional to report; list not inclusive):
- Reactive cellular changes associated with



inflammation (includes typical repair)



radiation



intrauterine contraceptive device (IUD)

- Glandular cells status post hysterectomy
- Atrophy
OTHER
- Endometrial cells (in a woman > 40 years of age)
(Specify if ‘negative for squamous intraepithelial lesion’)

Anatomy and diagnosis

BETHESDA SYSTEM 2001

INTERPRETATION/RESULT

EPITHELIAL CELL ABNORMALITIES
SQUAMOUS CELL
- Atypical squamous cells: - of undetermined significance (ASC-US)

- cannot exclude HSIL (ASC-H)

- Low grade squamous intraepithelial lesion (LSIL)
encompassing: HPV/mild dysplasia/CIN 1
- High grade squamous intraepithelial lesion (HSIL)
encompassing: moderate and severe dysplasia, CIS/CIN 2 and CIN

3
with features suspicious for invasion (if invasion is suspected)

- Squamous cell carcinoma
GLANDULAR CELL
- Atypical: - endocervical cells/ endometrial cells/ glandular cells (NOS or specify in

comments)

- Atypical: - endocervical/ glandular cells, favor neoplastic
- Endocervical adenocarcinoma in situ
- Adenocarcinoma: - endocervical

- endometrial
- extrauterine
- not otherwise specified (NOS)

OTHER MALIGNANT NEOPLASMS: (specify)

Anatomy and diagnosis

Papanicolau and Bethesda

SQUAMOUS CELLS ABNORMALITIES

 

formerly CIN I, CIN II, CIN III

 

currently

currently

LSIL

LSIL

or LGSIL ( low grade sqamosus interaepithelial

or LGSIL ( low grade sqamosus interaepithelial

lesion)

lesion)

-

encompassing: HPV/mild dysplasia/CIN 1

 

HSIL or HGSIL (high grade squamosus

interaepithelial lesion)

-

encompassing: moderate and severe dysplasia,

CIS/CIN 2 and CIN 3

and

HSIL

with features suspicious for invasion

Anatomy and diagnosis

COLPOSCOPY IN DIRECT

DIAGNOSIS OF

PATHOLOGICAL CHANGES

OF UTERINE CERVIX

Anatomy and diagnosis

CERVICAL EROSIONS



Simple cervical erosion



Papillariy cervical erosion



Follicular cervical erosion



Sanguinans cervical erosion

Anatomy and diagnosis

MAKROSCOPIC IMAGE OF CERVICAL

EROSION by Matthews and Hymms

Erosion I

º

-

2% of

carcinomas

Erosion II º-

27% of

carcinomas

Erosion III º-

54% of

carcinomas

Erosion IV º-

17% of

carcinomas

Anatomy and diagnosis

Hinselmann 1924

COLPOSCOPY 4 – 50 x

magnification

......

WIDEN COLPOSCOPIC

EXAMINATION

Anatomy and diagnosis

WIDEN COLPOSCOPIC
EXAMINATION



3% acetic acid- Hinselmann test



Lugol solution- Lahme-Schiller test



3-10% silver nitrate



hematoxylin- Antoine test



toluidine blue- Richart test



noradrenaline, vasopressin test



Filters

Anatomy and diagnosis

Anatomy and diagnosis

Anatomy and diagnosis

Anatomy and diagnosis

Anatomy and diagnosis

Anatomy and diagnosis

Anatomy and diagnosis

Anatomy and diagnosis

SUSPICIOUS COLPOSCOPIC
IMAGES

1.

Leukoplakia

2.

Punctate lesions

3.

Papillary basis

4.

Erosion

5.

Abnormal vascular pattern

6.

Jodide negative areas of
paraepidermoidal epithelium

Anatomy and diagnosis

Anatomy and diagnosis

Anatomy and diagnosis

Anatomy and diagnosis

Anatomy and diagnosis

Anatomy and diagnosis

Anatomy and diagnosis

VAGINITIS:



Trichomonas vaginalis



Candida albicans



Bacterial Vaginosis



Allergy and atrophy

Anatomy and diagnosis

Vaginal pH in diagnostic the

vaginal infections

Physiologic

BV

vaginal pH

4.5

Candidiasis

Trichomoniasis

Anatomy and diagnosis

Bacterial Vaginosis



Clinical syndrome recognized as a
polymicrobial superficial vaginal
infection involving a loss of the
normal lactobacilli and an
overgrowth of anaerobes.



It may be the cause of up to one half
of cases of vaginitis in all women
and the cause of from 10 to 30
percent of cases in pregnant women

Anatomy and diagnosis

Diagnostic Criteria for

Bacterial Vaginosis



Homogeneous vaginal discharge (color and

amount may vary)



Presence of clue cells (greater than 20%)

Clue cells -epithelial cells with clumps of bacteria

on their surface



Amine (fishy) odor when potassium

hydroxide solution is added to vaginal

secretions (commonly called the "whiff test")



Vaginal pH greater than 4.5



Absence of the normal vaginal lactobacilli

NOTE: At least three of these criteria must be present for diagnosis.

Anatomy and diagnosis

Morbidity Associated with

Bacterial Vaginosis

Post induced-abortion pelvic inflammatory

disease

Post-hysterectomy vaginal cuff cellulitis
Plasma cell endometritis
In pregnant women:

Amniotic fluid infection

Clinical chorioamnionitis
Postpartum endometritis
Premature rupture of the membranes
Preterm delivery
Low birth weight

Anatomy and diagnosis

Treatment Regimens for

Bacterial Vaginosis

Oral treatment

Metronidazole

Clindamycin

Topical treatment

Clindamycin 2%

vaginal cream

Metronidazole vaginal

gel

500 mg twice daily for

seven days

or

2 g in a single dose

300 mg twice daily for

seven days

5 g at bedtime for

seven days

5 g twice daily or at

bedtime for five days

Anatomy and diagnosis

INFERTILITY

DIAGNOSIS

Anatomy and diagnosis

Hysterosalpingography

(HSG)



Hysterosalpingogram- x-ray imaging
of the uterus and fallopian tubes
after instillation of a contrast liquid



Routine infertility evaluation (basic
test)



Assess morphology of endocervical
canal, uterine cavity, tubes.



Rule out tubal occlusion, synechiae,
uterine anomalies.

Anatomy and diagnosis

Contraindications to HSG:

1.

active PID with abdominal

tenderness or palpable mass

2.

recent uterine/tubal surgery

3.

active uterine bleeding

4.

pregnancy (schedule exam before

ovulation to avoid early
pregnancy)

Anatomy and diagnosis

Normal hysterosalpingogram.

A smooth triangular uterine cavity and spill

from the ends of both tubes.

Anatomy and diagnosis

HSG showing a normal uterus and blocked

tubes

No "spill" of dye is seen at the ends of the

tubes

Anatomy and diagnosis

Hysterosalpingogram showing a uterus with

a myoma that is pushing in to the cavity.

Anatomy and diagnosis

A hysterosalpingogram indicate

intrauterine adhesions (synechia

)

Anatomy and diagnosis

Tubal Recannulization and

Selective Salpingography

 

                                                                   

 

    

    

    

    

    

    

    

    

    

    

    

    

    

    

    

    

 

Anatomy and diagnosis

Selective hysterosapingography, or proximal

tubal cannulization may open the tubes

avoiding surgery.

Anatomy and diagnosis

LAPAROSCOPY

Anatomy and diagnosis

The camera and instruments are inserted into the

abdomen or chest through small skin cuts allowing

the surgeon to explore the whole cavity without the

need of making large standard openings dividing

skin and muscle.

Anatomy and diagnosis

After the cut is made in the umbilical area a special

( Veress) needle is inserted to start insufflation. A

pressure regulator CO2 insufflator is connected to

the needle. The pressure obtained should not be

beyond 15 mmHg.

Anatomy and diagnosis

After satisfactory insuflation the needle is

removed and a 10 mm trocar is inserted through

the previous umbilical wound.

Anatomy and diagnosis

Pelvic laparoscopy is used both for
diagnosis and for treatment. It may
be recommended for:



pelvic pain due to



uterine tissue found outside the uterus in the abdomen

(endometriosis)



infections (pelvic inflammatory disease) not responsive to drug

therapy



suspected twisting (torsion) of an ovary



ovarian cyst



scar tissue (adhesions) in pelvis



puncture through the uterus (uterine perforation) following D & C or

by an IUD



evaluation of infertility



sterilization (tubal ligation)



evaluation and removal of an abnormal pelvic mass (such as in a

fallopian tube or ovary) that was confirmed previously by abdominal

ultrasound



removal of uterine fibroids (myomectomy)



removal of uterus (hysterectomy)



surgical treatment of tubal pregnancy in a hemodynamically stable

patient



evaluation of a woman who may have appendicitis or salpingitis

Anatomy and diagnosis

Laparoscopic view of a normal pelvis.

Uterus in midline. Tubes and ovaries (white

structures) also visible.

Anatomy and diagnosis

Photo shows blood-stained ascites fluid with

an adhesion of small bowel to the

abdominal wall.

Anatomy and diagnosis

The omentum with white deposits which

represent metastatic tumor.

Anatomy and diagnosis

A biopsy is taken of one of the tumor

deposits on the abdominal wall.

Anatomy and diagnosis

The ectopic pregnacy is visualized in the

ampullary region of the left fallopian tube.

Anatomy and diagnosis

Contraindications to

laparoscopy:



Circulatory and respiratory
insufficiency



Hypovolemic shock



Ileus



Peritonitis



Abdominal or diaphragmic hernia



Tumors in abdominal cavity

Anatomy and diagnosis

Pelvic laparoscopy is also not

recommended for patients

with:



severe obesity



existing severe pelvic adhesions
from previous surgeries

Anatomy and diagnosis

Pelvic Laparoscopy: Risks



Risks for any anesthesia are:

•

reactions to medications

•

problems breathing



Risks for any surgery are:

•

bleeding

•

infection

•

damage to adjacent organs

Anatomy and diagnosis

HYSTEROSCOPY



Assess the endocervical canal,
uterine cavity and uterine
openings of the oviducts.



Enables to make the intrauterine
operations.

Anatomy and diagnosis

Hysteroscopic view of a uterine septum.

A septum can cause recurrent miscarriage.

Anatomy and diagnosis

A large polyp at the top of the uterine cavity

Anatomy and diagnosis

The loop of the resectoscope can be seen in the
foreground at the internal os of the cervix and the
myoma in the background. The endometrium
appears atrophic because the patient was treated
preoperatively with a GnRH agonist to diminish the
size of the myoma

Anatomy and diagnosis

The myoma is released by progressive shaving of the
stalk. The loop of the resectoscope is placed at the
most distant portion, and current is applied as the
resectoscope is drawn toward the surgeon.

 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Anatomy and diagnosis

Contraindications to
hysteroscopy:



Infections of reproductive organs



Massive bleeding from uterus



Pregnacy



Cervical cancer

Anatomy and diagnosis

Hysteroscopy.

Risks.



Uterine perforation



Bleeding



Infection



Pulmonary embolism (rare)

Anatomy and diagnosis

Tumor markers.



Useful in the follow-up



More useful markers:



β-HCG- in gestational trophoblastic neoplasia



CA 125- in ovary cancer, but also
endometrial, cervical and breast cancer



genetic markers : BRCA1 and BRCA2
mutations



CA 19-9- in ovary cancer